MIPS 2020 Proposed Rule: The Climb Gets Steeper

The QPP proposed rule for 2020 performance year was released last week. The proposed rule takes into consideration the feedback CMS has received from clinicians and stakeholders and the participation and performance data for the past MIPS performance years. Based on that, CMS is trying to better align the performance categories, simplifying the requirements, and making the MIPS Quality measures more outcome focused.

As anticipated, the requirements get steeper. Performance thresholds and data completeness have increased substantially. At the same time, many policies introduced for the 2019 performance year remain unaltered for 2020.

Let's dive right into it. 

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2019 vs. 2020 Summary of Proposed Changes

2019
2020
Performance category weights Quality-45%

Cost-15%

Promoting Interoperability–25%

Improvement Activities–15%
Quality-40%

Cost-20%

Promoting Interoperability–25%

Improvement Activities–15%
Payment Adjustment Range +/- 7% +/- 9%
Performance Threshold 30 points 45 points
Additional Performance Threshold 75 points 80 points
Data Completeness 60% 70%

As you can see, the scales of Quality and Cost categories are slowly swinging into balance. The proposed weight distribution for 2021 will be 35% and 25% respectively, and scales will even out in 2022 with both Quality and Cost categories weighing at 30% each.

Balancing of Weight for Quality and Cost Performance Categories for MIPS

Performance Thresholds will continue to climb up with each performance year requiring clinicians to be involved with all the performance categories; while the payment adjustment range will stay at +/-9% for future years.

MIPS Performance Threshold Trend 2017-2021

Quality Category

One major proposed change for the Quality performance category is the increase in the Data Completeness requirement from 60% to 70% (clinicians will need to report on at least 70% of their patients).

Certain Benchmarks Modified & Measure Removal: Flat percentage benchmarks are proposed for the measures where treatment of patients as per the current benchmarks could be inappropriate for certain patients. For instance, performance rate above 90% would fall in the top decile. Policies for the topped out measures and benchmark determination remains the same.

In case a benchmark cannot be established for a measure due to inadequate reporting volume or case minimum for two consecutive years, it would be considered for removal.

MIPS Value Pathways (MVPs) are proposed from 2021 performance year with intent to align the measures across all performance categories and reduce reporting burden. The goal is also to ensure that the measures are meaningful to patient care while being relevant to clinicians’ scope of practice.

Cost Category

TPCC and MSPB Revised: Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary (MSPB) measures, which are the core Cost measures are proposed to be revised specifically in regards to measure attribution. The measure attribution would be different for individuals and groups as well as surgical and medical patients.

10 new episode-based measures are proposed to be added to the 8 existing measures. No changes are proposed for measure attribution for both old and new episode-based measures. Case minimums for the measures remain unchanged

1. Acute Kidney Injury Requiring New Inpatient Dialysis

2. Elective Primary Hip Arthroplasty

3. Femoral or Inguinal Hernia Repair

4. Hemodialysis Access Creation

5. Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

6. Lower Gastrointestinal Hemorrhage

7. Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels

8. Lumpectomy Partial Mastectomy, Simple Mastectomy

9. Non-Emergent Coronary Artery Bypass Graft (CABG)

10. Renal or Ureteral Stone Surgical Treatment


Promoting Interoperability Category

Small changes have been proposed for the PI category for 2020 MIPS performance year. This includes removal of the Verify Opioid Treatment Agreement measure and making the Query of Prescription Drug Monitoring Program (PDMP) measure optional.

The PI category for Hospital-Based-Groups will be automatically re-weighted to the Quality category, if ≥ 75% of clinicians in the group meet the definition of a hospital-based individual MIPS eligible clinician (as opposed to 100% for the 2019 MIPS performance year).


PI Updates for 2019 Also Announced

Two important updates have been announced for 2019 MIPS Performance Year:

  1. Under the e-Prescribing objective, It is proposed to require Yes/No response for the bonus measure Query of Prescription Drug Monitoring Program (PDMP) instead of a numerator/denominator finalized in 2019 Final Rule.

  2. If an exclusion is claimed for the Support Electronic Referral Loops by Sending Health Information” measure, the points will be redistributed to the “Provide Patients Access to Their Health Information” measure. This was pending from the 2019 Final Rule.


Improvement Activities Category

Group Reporting: To get the IA credit for a group/Virtual group, 50% of clinicians in a group will be required to participate for the same 90 continuous days as opposed to just one provider in the group.

Change in IA Inventory: Addition of 2 activities is proposed, along with removal of 15 existing activities and modification of 7 existing activities. Additionally, policy for removal of an Improvement Activity has been proposed.

Rural areas definition will be updated to align the ZIP codes with the Federal Office of Rural Health Policy (FORHP) instead of the Health Resources and Services Administration (HRSA) used for the previous performance years.

Patient Centered Medical Home criteria have been updated with focus on whole-person, integrated care.

Overarching Changes

Reducing Reporting Burden: In order to reduce the reporting burden for clinicians, CMS has proposed updates in policies for Qualified Registries and Qualified Clinical Data Registries (QCDRs) in terms of providing performance feedback, supporting QCDR measures, and activities that result in improvement care quality. Health IT vendors will be required to support data submission for at-least one performance category.

Public reporting of aggregated MIPS data beginning with 2018 MIPS performance year later in 2019 has been also proposed.

Performance Category Reweighting Due to Data Integrity Issues: In the event that data is compromised due to rare circumstances outside the control of MIPS eligible clinicians, CMS will determine reweighting the PI and/or the Quality category depending on the data impacted.


Things that Will Stay the Same as 2019

Performance Period: The performance period for all performance categories will remain same as performance year 2019.

  • Quality and Cost - Full calendar year (Jan 1, 2020 - Dec 31, 2020)

  • PI and IA - Minimum of 90 continuous days within the performance year

Eligible Clinician Types: No new eligible clinician types have been added for 2020, and it remains the same as for 2019.

Low Volume Threshold (LVT) and Opt-In: Same criteria will apply for determining the LVT as well as for clinicians to opt-in.

  1. Bill > $90,000 in Medicare Part B allowed charges AND

  2. Provide care to > 200 Medicare Part B beneficiaries AND

  3. Provide >200 covered professional services

Scoring Methodologies: Same scoring policies will apply for measures, activities, and performance category scoring including the 3 point floor for scored measures, improvement scoring, small-practice bonus, high-priority measures, and end-to-end electronic reporting bonus.

Quality Measures: Scoring for Topped-Out measures and those impacted by Clinical Guideline changes will be scored in the same way as in 2019.

Facility-Based Clinicians: The definition and determination of Facility-based clinicians along with the scoring methodology will remain unchanged from 2019.

Collection and Submission of Data: All the collection types available for data submission in the performance year 2019 are proposed for 2020 too, that is eCQMs(EHR Measures), MIPS CQMs (Registry measures), QCDR measures, CAHPS for MIPS survey, and CMS Web Interface measures. How eligible clinicians can submit data to CMS is also proposed to stay intact including Direct, log in and upload, log in and attest, Medicare Part B claims and the CMS Web Interface.

CMS is requesting comments and feedback on the 2020 QPP Proposed Rule. The comment period is open til September 27, 2019. Include file code CMS-1715-P when submitting your comment via http://www.regulations.gov. After the comment period, the Final Rule will be released in late Fall 2019. Stay tuned.
 

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